NOTE: All lines must be completely filled in Roman letters and in English, wherever possible. No PO boxes; provide cross streets where only PO boxes are available.
1. CONSIGNEE / DISTRIBUTOR / IMPORTER INFORMATION
NAME & JOB TITLE(First Name, Middle Initial, Last Name)
COMPANY NAME / STREET ADDRESS
VILLAGE / TOWN / CITY
TELEPHONE / STATE / REGION / POSTAL CODE
FAX or E-MAIL / COUNTRY
COMPANY WEBSITE
(if available)
2. END USER INFORMATION (PERSON WHO WILL BE USING THE PRODUCT)
NAME & JOB TITLE(First Name, Middle Initial, Last Name)
COMPANY NAME / STREET ADDRESS
VILLAGE / TOWN / CITY
TELEPHONE / STATE / REGION / POSTAL CODE
FAX or E-MAIL / COUNTRY
COMPANY WEBSITE
(if available)
3. USE OF ITEMS BY END USER NAMED IN SECTION 2
E & Z MODEL(S)/PRODUCT(S) ORDERED & INTENDED USE/APPLICATION4. SITE/FACILITY LICENSE INFORMATION (if applicable) EXEMPT Quantity (if import license is requested but not required)
LICENSE/PERMIT NO.: AMENDMENT/REVISION: EXPIRATION DATE:
5. STATEMENT OF END USER
In accordance with the terms of the contract, we confirm the following:· The goods will not be re-routed or exported to embargo countries unless specifically licensed. The US embargo countries include: Cuba, Iran, Iraq, North Korea, Sudan, and Syria [Ref. US NRC 10 CFR 110.28].
· We will not re-sell and/or re-export to, or use products containing Special Nuclear Material (plutonium, uranium-233, or uranium enriched in the isotopes uranium-233 or uranium-235) in countries classified under restricted destinations (Afghanistan, Andorra, Angola, Burma (Myanmar), Djibouti, India, Israel, Pakistan, South Sudan and Libya) unless specifically licensed [Ref. US NRC 10 CFR 110.29].
· The goods are properly licensed and approved for use at the address in Section 2.
· The goods, or a replica of them will not be used for purposes associated with military, chemical, biological, or nuclear weapons, explosives, or missile production or for missiles capable of delivering such weapons.
· All of the facts contained in this statement are true and correct to the best of our knowledge and we do not know of any additional facts which are inconsistent with the above statement. We shall promptly send a supplemental statement to E & Z, disclosing any change of facts or intention set forth in this statement which occurs after the statement has been prepared and forwarded.
We understand the “goods” includes, but is not limited to, radioactive materials, sealed sources, technology, confidential information, equipment, product development, and other products or services not specifically stated in this document but may be part of the contractual agreement.
PRINT NAME and SIGNATURE OF END USER
DATE:
IPL Form483 Date Printed: 3-Jun-15
Revision: E Page 1 of 1